Fundamentals of Nursing

A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest? Choose all that apply

• Move more and sit less throughout the day.

• Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity.

• Perform muscle-strengthening activities using light weights on 2 or more days a week.

• Walk at a vigorous pace with wife at least 150 minutes over five days a week.

• Focus on balance training.

Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker? (Select all that apply.)

• A walker is useful for patients who have impaired balance.

• The patient uses a walker by pushing the device forward.

• Leaning over the walker improves the patient’s balance.

• Walkers should not be used on stairs.

• If the patient has difficulty advancing the walker, a walker with wheels is an option.

The following statements are the recommended guidelines on performing hand washing according to WHO, EXCEPT

• Before patient contact

• After body fluid exposure risk

• Before doing hand hygiene

• After contact with patient surrounding

• None of the above

Upon assessing a 28-year-old patient’s temperature, you notice the temperature you have taken is 39.0C. What will be your next step?

• Notify the physician

• Reassess the temperature after a few minutes and ask patient for any other symptoms

• Document your findings

• Have a co-worker re-check the temperature

You notice that your patient seems to have an irregular pulse rate and rhythm. What would be your next step?

• Take the pulse for 1 full minute

• Notify the physician

• Document your findings

• Tell the patient that he/she might have a heart problem

Some patient may have such shallow respirations that a nurse may have difficulty assessing their respirations. What would be the most appropriate nursing action to properly assess for the patient’s respiration?

• Use a stethoscope and auscultate the lung sounds

• Hook the patient to a cardiac monitor

• Tell your co-worker to check the patient’s respiratio

• Have the patient in high fowlers position

This is the series of sounds for which to listen when assessing blood pressure

• Tinnitus

• Borborygmus

• Ronchi

• Korotkoff

It is defined as a drop of at least 20 mm Hg systolic or 10 mm Hg diastolic in blood pressure within 3 minutes of quiet standing after being supine

• Orthostatic hypotension

• Orthopnea

• Decreased cardiac output

• Vasovagal syncope

In medical hand washing, it is important to keep hands lower than the elbows, so that water flows from arms to the fingertips; the rationale behind this technique is:

• Prevent the nurses’ clothes to get wet which can lead to contamination

• The position is ergonomically correct

• Hands are more contaminated than forearms

• To maintain the flow of water directly in the sink and prevent splashing water to the surrounding area

What is the primary purpose of the nursing process in patient care?

• To diagnose diseases

• To provide a structured framework for patient care

• To prescribe medication

• To perform surgical procedures